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Scott Reed, M.D. Abdominal Trauma. “Abdomen” “Abdomen” –Derived from Latin word “abdere” which means “to hide” –Often referred to as “the black box.”

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Presentation on theme: "Scott Reed, M.D. Abdominal Trauma. “Abdomen” “Abdomen” –Derived from Latin word “abdere” which means “to hide” –Often referred to as “the black box.”"— Presentation transcript:

1 Scott Reed, M.D. Abdominal Trauma

2 “Abdomen” “Abdomen” –Derived from Latin word “abdere” which means “to hide” –Often referred to as “the black box.” “Follow the clues”

3 Abdominal Trauma Catagorized according to Mechanism Catagorized according to Mechanism –Penetrating Gunshot Gunshot Stabbings Stabbings –Blunt Motor vehicle / Motorcycle accidents Motor vehicle / Motorcycle accidents Assault Assault Falls Falls Pedestrians struck Pedestrians struck

4 Abdominal Trauma Trauma. Fourth ed. Mattox

5 Abdominal Trauma Trauma, Fourth ed. Mattox

6 Abdominal Trauma Major source of Morbidity and Mortality Major source of Morbidity and Mortality Rapid Diagnosis is Key Rapid Diagnosis is Key –Autopsy study comparing two trauma systems –100 consecutive deaths San Francisco County – Trauma system where all major injuries went to a Level I trauma center San Francisco County – Trauma system where all major injuries went to a Level I trauma center Orange County – Transported to nearest hospital Orange County – Transported to nearest hospital West, JG, Trunkey, DD, Lim, RC: Systems of Trauma Care: A study of two counties. Arch Surg 114:455, 1979

7 Abdominal Trauma San Francisco Co. San Francisco Co. –16 deaths – 1 considered preventable –Missed Thor. Aortic injury Orange County Orange County –30 deaths- 22 considered preventable –10 of 22 died due to shock from unrecognized abdominal injury –8 of 10 died in the first 6 hours West, JG, Trunkey, DD, Lim, RC: Systems of Trauma Care: A study of two counties. Arch Surg 114:455, 1979

8 Abdominal Trauma - Diagnosis Physical Exam Physical Exam –Requires neurologically intact patient Pain / Tenderness Pain / Tenderness Guarding Guarding Rebound / Peritoneal signs Rebound / Peritoneal signs –All that’s needed in penetrating trauma –All that’s needed in hemodynamically unstable blunt trauma.

9 Abdominal Trauma – Diagnosis Physical Exam Physical Exam –Penetrating – Gunshot wounds (high energy injury) Determining the trajectory can give an idea of what is injured Determining the trajectory can give an idea of what is injured Need even number of holes and/or bullets on X-ray Need even number of holes and/or bullets on X-ray Must be careful since bullets can “settle” to dependent areas Must be careful since bullets can “settle” to dependent areas

10 Abdominal Trauma – Diagnosis Physical Exam Physical Exam –Penetrating – Stabbing (Low energy) More difficult since there is only an entrance and no “trajectory” More difficult since there is only an entrance and no “trajectory” Injury can be far from the injury Injury can be far from the injury May be all that is needed in hemodynamically stable patients (observation). No good study to pick up hollow viscus injuries. May be all that is needed in hemodynamically stable patients (observation). No good study to pick up hollow viscus injuries.

11 Abdominal Trauma - Diagnosis Ultrasound (F.A.S.T.) Ultrasound (F.A.S.T.) –Focused Abdominal Sonogram for Trauma Really is fast (done in the trauma bay) Really is fast (done in the trauma bay) Non-invasive and can be repeated Non-invasive and can be repeated Only determines the presence of fluid in the abdomen (between 80 – 95% sensitive) Only determines the presence of fluid in the abdomen (between 80 – 95% sensitive) Not very specific (which organ) or what type of fluid (blood, succus, ascites) Not very specific (which organ) or what type of fluid (blood, succus, ascites)

12 Abdominal Trauma – X-Rays Can show evidence of free air (hollow viscus injury) Can show evidence of free air (hollow viscus injury) Can help determine the trajectory of the missile Can help determine the trajectory of the missile

13 41 y/o female S/P MVA

14 Level of the Aortic Arch

15 Abdominal Trauma - Diagnosis Diagnostic Peritoneal Lavage (DPL) Diagnostic Peritoneal Lavage (DPL) –Has all but been replaced by FAST exam –Inserted catheter into abdomen Gross blood (10cc or more) - positive Gross blood (10cc or more) - positive –Instilled 1 liter normal saline Over 100,000 RBC’s, 500 WBC, bile or fibers of food on micro - positive Over 100,000 RBC’s, 500 WBC, bile or fibers of food on micro - positive

16 Abdominal Trauma - Diagnosis Diagnostic Peritoneal Lavage Diagnostic Peritoneal Lavage –Invasive – 1% injury rate –Oversensitive (small amount of blood can make a positive by micro) – 50cc –Non-specific –Problem in the era of non-operative management of solid organ injury –? Role in CT with fluid but no solid organ injury (? Hollow viscus injury)

17 Abdominal Trauma - Diagnosis Computed Tomography (CT Scan) Computed Tomography (CT Scan) –Started in mid-1980’s and has revolutionize trauma care. Sees more than just the abdomen (spinal and pelvic fractures) Done in conjunction with the head and C-spine. Sees more than just the abdomen (spinal and pelvic fractures) Done in conjunction with the head and C-spine. More specific (solid organ injury) and examines the retroperitoneal areas (pancreas, kidney, duodenum) More specific (solid organ injury) and examines the retroperitoneal areas (pancreas, kidney, duodenum) Arterial injuries can be studied Arterial injuries can be studied

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19 Abdominal Trauma - Diagnosis CT Scan – Drawbacks CT Scan – Drawbacks –Misses hollow viscus injuries –Can’t evaluate the diaphragm –Involves IV contrast (allergic reactions 1:1000) and radiation –Tough to run a code in a donut (need a stable patient)

20 Abdominal Trauma - Angiography Using catheters via a femoral / brachial approach to occlude arteries Using catheters via a femoral / brachial approach to occlude arteries Used increasingly for solid organ injury Used increasingly for solid organ injury –Liver – Embolize either Right/Left hepatic arteries (Liver has both arterial and portal blood supplies) –Spleen – Can be selective or embolize the entire organ

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24 Abdominal Trauma - Angiography Can convert what would be a large and bloody case into a easily managed situation Can convert what would be a large and bloody case into a easily managed situation Doesn’t always work Doesn’t always work –Now operating later on a sicker patient –Can embolize too much and infarct other vascular beds All fluid isn’t blood – Can miss small bowel injuries All fluid isn’t blood – Can miss small bowel injuries

25 Abdominal Trauma - Observation Liver and Spleen injuries can be observed Liver and Spleen injuries can be observed –Acceptable in minor injuries with minimal bleeding seen on CT scan –Have to observe VERY closely Repeated abdominal exams Repeated abdominal exams Vital signs, dropping hematocrits Vital signs, dropping hematocrits –Have to be ready to operate if needed quickly

26 Abdominal Trauma - Diagnosis Laparoscopy Laparoscopy –Excellent for stable stab wounds (peritoneal penetration/diaphragm injury) –Hard to see everything Can “run the bowel” Can “run the bowel” hard to see retroperitoneum, lesser sac, and assess liver / spleen injuries hard to see retroperitoneum, lesser sac, and assess liver / spleen injuries –Invasive, expensive –may need to to open

27 Abdominal Trauma - Surgery Once thought that all repairs needed to be done at the initial surgery Once thought that all repairs needed to be done at the initial surgery –Long surgery / multiple repairs on hemodynamically unstable patients –Cold, Acidotic, Coagulopathic –Patients died

28 Abdominal Surgery - Surgery Damage Control surgery Damage Control surgery –Stop the bleeding and contamination and then get out. Pack the liver Pack the liver Staple out injured small bowel/colon (no anastamosis needed) Staple out injured small bowel/colon (no anastamosis needed) Vascular shunts Vascular shunts –Leave abd open or just close skin –Get to ICU for resuscitation/warming

29 Abdominal Trauma - Surgery Damage Control Surgery Damage Control Surgery –After 24 to 48 hours go back to the OR Patient is resuscitated, warm, stable Patient is resuscitated, warm, stable –Establish GI continuity –Wash out areas of contamination –Vascular repairs –Patients live

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31 Abdominal Trauma - Nursing The Open Abdomen The Open Abdomen –A clear, fenestrated plastic layer over the bowel and viscera (Vi-drape) –OR towel, Kerlex, or sponge in the dead space –Large drains in the gutters –Cover entire opening with occlusive dressing (Ioban) –Place drains to suction

32 Abdominal Trauma - Nursing Open Abdomen (VacPack, Blue Towel) Open Abdomen (VacPack, Blue Towel) –Can be done fast in the OR –Controls abdominal fluids (can measure) –Prevents abdominal compartment syndrome (more to follow) –Can be taken down in ICU to allow inspection of the abdomen

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34 Abdominal Trauma - Nursing Drains Drains –Placed in areas where fluid may collect. Near an anastomosis Near an anastomosis Pancreatic injury Pancreatic injury –Must look for changes in output Increase could signal a leak, or sudden stop could indicate the drain is clogged Increase could signal a leak, or sudden stop could indicate the drain is clogged Type and quality of the fluid (suddenly becomes bloody or bilious) Type and quality of the fluid (suddenly becomes bloody or bilious)

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38 Abdominal Trauma – Nursing Fistulas Fistulas –Abnormal connection between two epithelialized compartments. –Named for the two organs connected

39 Abdominal Trauma - Nursing Fistulas Fistulas –Enterocutaneous (Small bowel to skin) Most common Most common Usually involves the wound or incision Usually involves the wound or incision Will see bowel contents in the wound Will see bowel contents in the wound Often due to surgical mishaps Often due to surgical mishaps

40 Abdominal Trauma - Nursing Colocutaneous (colon to skin) Colocutaneous (colon to skin) Colovesicular (colon to bladder) Colovesicular (colon to bladder) The stomach, pancreas, gallbladder, arteries, and veins can all be involved in fistulas The stomach, pancreas, gallbladder, arteries, and veins can all be involved in fistulas

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42 Abdominal Compartment Syndrome

43 Abdominal Compartment Syndrome What is normal? At rest 0 – 5mmHg At rest 0 – 5mmHg Valsalva 60 – 80mmHg Valsalva 60 – 80mmHg Cough80cmH2O Cough80cmH2O Vomiting60cmH2O Vomiting60cmH2O Active liftingOver 150mmHg Active liftingOver 150mmHg –During lifting the pressure is related to the velocity of muscle contraction and comes back to baseline once the movement has ended

44 Abdominal Compartment Syndrome Grading System Grade I10 – 15mmHg Grade I10 – 15mmHg Grade II16 - 25mmHg Grade II16 - 25mmHg Grade III26 – 35mmHg Grade III26 – 35mmHg Grade IV>35mmHg Grade IV>35mmHg

45 Abdominal Compartment Syndrome Causes (Acute) –Intra-abdominal Bowel obstruction / Ileus Bowel obstruction / Ileus Ruptured AAA Ruptured AAA Mesenteric venous obstruction Mesenteric venous obstruction Abscess Abscess Pneumoperitoneum Pneumoperitoneum Intraperitoneal bleed / trauma Intraperitoneal bleed / trauma Viseral edema Viseral edema Retroperitoneal Retroperitoneal –Pancreatitis –Pelvic Frx/bleeds –Ruptured AAA Abdominal Wall Abdominal Wall –Burn Eschar –Massive hernia repair –Closing the tight abdomen

46 Abdominal Compartment Syndrome Constellation of Symptoms Renal failure Renal failure –Decreased urine output Respiratory failure Respiratory failure –Dec compliance, inc pulmonary edema / airway pressure Cardiac failure Cardiac failure –Decreased cardiac output (dec preload / inc afterload) Visceral failure Visceral failure –Dec blood flow to liver, bowel (bacterial translocation) Neurologic complications Neurologic complications –Increased intracranial pressure Abdominal wall “failure” Abdominal wall “failure” –Dehissence, hernia formation

47 Abdominal Compartment Syndrome Types Primary Primary –hypertension (IAH) Secondary A process within or involving the abdomen itself which leads to increased intra-abdominal Secondary Secondary –IAH which results even though no direct abdominal injury has occurred –Often overlooked –Strongly related to resuscitation fluids (iatrogenic)

48 Saggi et. al Journal of Trauma 1998

49 Abdominal Compartment Syndrome Measuring pressures Bladder Pressure (gold standard) Bladder Pressure (gold standard) –Clamp foley catheter –Instill 50-100cc saline into bladder –Use pressure transducer via sampling port Accurate – Corresponds well with direct intra-abdominal catheters and insufflation during laparoscopy Accurate – Corresponds well with direct intra-abdominal catheters and insufflation during laparoscopy Reliable and reproducible Reliable and reproducible

50 Abdominal Compartment Syndrome New Perspectives on Old Concepts

51 Abdominal Compartment Syndrome EVMS Experience Resuscitation greater than 12 liters in the first 24 hours was a risk factor for the development of secondary abdominal compartment syndrome Resuscitation greater than 12 liters in the first 24 hours was a risk factor for the development of secondary abdominal compartment syndrome R.C. Britt, et. al.

52 Balough, The American J. of Surg. 2003

53 Abdominal Compartment Syndrome Possible Prevention Stratagies ACS carries high mortality ACS carries high mortality Abdominal decompression also has high morbidity and mortality Abdominal decompression also has high morbidity and mortality –At risk groups can be identified High volume resuscitations (burns, traumas) High volume resuscitations (burns, traumas) Pt’s post hemorrhage and shock Pt’s post hemorrhage and shock –ACP can be easily measured

54 Abdominal Compartment Syndrome Peritoneal Catheter Placement –Abdominal pressures over 20 mmHg –Abdominal perfusion pressures (APP) less than 50mmHg Abdominal perfusion pressure equals the mean arterial pressure minus the abdominal pressure. (MAP – ACP = APP) Abdominal perfusion pressure equals the mean arterial pressure minus the abdominal pressure. (MAP – ACP = APP)

55 Results – Total Group Thirty minutes after the DPL catheter was placed: (Avg starting ACP was 24.9mmHg) Thirty minutes after the DPL catheter was placed: (Avg starting ACP was 24.9mmHg) –Average ACP decreased 7.7mmHg (p=0.003) –Average MAP increased 9.7mmHg (p=0.02) –Average APP increased 17.4mmHg (p=0.007) –Average Pulm Compliance increased 7.9 (p=0.002 )

56 Abdominal Trauma – Case Report 19 y/o male – motorcycle crash 19 y/o male – motorcycle crash –Multiple rib fractures –Facial fractures –Bilateral Tibia/fibula fractures –Grade I spleen laceration

57 Abdominal Trauma – Case Report Had both lower extremities repaired on HD#2 Had both lower extremities repaired on HD#2 Rib fractures managed with pain control and pulmonary toilet Rib fractures managed with pain control and pulmonary toilet Facial fractures repair on HD#5 Facial fractures repair on HD#5 Spleen observed Spleen observed Left ICU on HD#4 and went to floor Left ICU on HD#4 and went to floor

58 Abdominal Trauma – Case Report Morning rounds HD#8 Morning rounds HD#8 –HR – 70 to 80 bpm –BP 120/75 –Using only Percocet for pain –H/H – 11/33 Planning D/C home soon Planning D/C home soon

59 Abdominal Trauma – Case Report 10pm Nurse called for increased pain in Left Shoulder 10pm Nurse called for increased pain in Left Shoulder –Determined this was a new complaint and no shoulder injury was documented –Repeated vital signs HR – 110 HR – 110 BP – 95/50 BP – 95/50 Patient was diaphoretic and pale Patient was diaphoretic and pale

60 Abdominal Trauma – Case Report Nurse immediately contacted house staff with new complaints and vital signs Nurse immediately contacted house staff with new complaints and vital signs –Patients seen and examined –Abdomen now tender with guarding –Repeat H/H – 6.5/19

61 Abdominal Trauma – Case Report Emergent Abdominal CT Scan revealed massive hemoperitoneum and delayed rupture of the spleen Emergent Abdominal CT Scan revealed massive hemoperitoneum and delayed rupture of the spleen Taken immediately to OR for emergent splenectomy Taken immediately to OR for emergent splenectomy Did well and was discharged on HD#13 Did well and was discharged on HD#13

62 Abdominal Trauma – Nursing Quote “I don’t need to know exactly what is wrong…I just need to know that something is wrong” “I don’t need to know exactly what is wrong…I just need to know that something is wrong” My Mom My Mom


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